- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $854.50 / $854.50 / $985.97
| Professional | | $854.50 | $854.50 | $985.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $926.75 / $926.75 / $1,287.02
| Facility | | $926.75 | $926.75 | $1,287.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $787.74 / $787.74 / $923.92
| Professional | | $787.74 | $787.74 | $923.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $926.75 / $926.75 / $1,287.02
| Facility | | $926.75 | $926.75 | $1,287.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $787.74 / $787.74 / $923.92
| Professional | | $787.74 | $787.74 | $923.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $582.40 / $1,114.83 / $2,024.32
| Professional | | $582.40 | $1,114.83 | $2,024.32 |